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The document discusses skin injury and wound healing. It notes that skin is the body's first line of defense and most frequently injured tissue. It describes different types of open and closed wounds like abrasions, lacerations, and contusions. The document outlines skin anatomy and the process of wound healing, including hemostasis, inflammation, epithelialization, and complications like infection. It emphasizes the importance of thorough wound assessment and documentation of factors like location, size, depth, wound bed appearance, and exudate.
The document discusses skin injury and wound healing. It notes that skin is the body's first line of defense and most frequently injured tissue. It describes different types of open and closed wounds like abrasions, lacerations, and contusions. The document outlines skin anatomy and the process of wound healing, including hemostasis, inflammation, epithelialization, and complications like infection. It emphasizes the importance of thorough wound assessment and documentation of factors like location, size, depth, wound bed appearance, and exudate.
The document discusses skin injury and wound healing. It notes that skin is the body's first line of defense and most frequently injured tissue. It describes different types of open and closed wounds like abrasions, lacerations, and contusions. The document outlines skin anatomy and the process of wound healing, including hemostasis, inflammation, epithelialization, and complications like infection. It emphasizes the importance of thorough wound assessment and documentation of factors like location, size, depth, wound bed appearance, and exudate.
Skin is the largest, most important organ 16% of total body weight Function Protection Sensation Temperature Regulation etc Introduction to Skin Injury Skin Injuries Skin is the bodys first layer of defense against injury Most frequently injured body tissue Different Types of Skin Injuries Abrasions Blisters Skin Bruises Incision Laceration Puncture Wound Epidemiology Open Wounds Over 10 million wounds present to ED Most require simple care and some suturing Up to 6.5% may become infected Closed Wounds More Common Contusions Introduction to Skin Injury Anatomy Skin Layers Epidermis Outermost, avascular layer of dead cells Helps prevent infection Sebum Waxy, oily substance that lubricates surface Dermis Upper Layer (Papillary Layer) Loose connective tissue, capillaries and nerves Lower Layer (Reticular Layer) Integrates dermis with SQ layer Blood vessels, nerve endings, glands Sebaceous & Sudoriferous Glands Subcutaneous Adipose tissue Heat retention Langers Line Tension Lines Natural patterns in the surface of the skin revealing tension within Type of Injury Closed Wounds Contusions Erythema Ecchymosis Hematomas Crush Injuries Open Wounds Abrasions Lacerations Incisions Punctures Impaled Objects Avulsions Amputations Abrasions Minor skin injuries Caused by a shear force Skin is scraped with sufficient force, usually in one direction, against a rough surface The greater the applied force, the more layers of skin that are scraped away Blisters Minor skin injuries Caused by repeated application of shear in one or more directions Occurs when a shoe rubs back and forth against foot Result is the formation of a pocket of fluid between the multiple layers of skin Skin Bruises Contusion Injuries resulting from compression sustained during a blow Damage of the underlying capillaries Causes the accumulation of blood within the skin Incision and Laceration Incision Clean cut Produced by the application of a tensile force to the skin as it is stretched along a sharp edge Laceration Irregular tear in the skin Typically results from a combination of tension and shear Puncture Wound Formed when a sharp object penetrates the skin and underlying tissues with tensile loading Puncture wound can come from: Shoe spike Nail
Burns Burns are a type of injury caused by thermal, electrical, chemical, or electromagnetic energy. Smoking and open flame are the leading causes of burn injury for older adults, while scalding is the leading cause of burn injury for children.
Classification First-degree (superficial) burns First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Second-degree (partial thickness) burns Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. Third-degree (full thickness) burns Third-degree burns destroy the epidermis and dermis. Third- degree burns may also damage the underlying bones, muscles, and tendons. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed.
Hemostasis Bodys natural ability to stop bleeding & the ability to clot blood Begins immediately after injury Inflammation Local biochemical process that attracts WBCs Epithelialization Migration of epithelial cells over wound surface Wound Healing (continued) Neovascularization New growth of capillaries in response to healing Collagen Synthesis Fibroblasts: Cells that form collagen Collagen: Tough, strong protein that comprises connective tissue Cont Infection Most common and most serious complication of open wounds 1:15 wounds seen in ED result in infection Delay healing Spread to adjacent tissues Systemic infection: Sepsis Presentation Pus: WBCs, cellular debris, & dead bacteria Lymphangitis: Visible red streaks Fever & Malaise Localized Fever Complication Infection Risk Factors Hosts health & pre-existing illnesses Medications (NSAIDs) Wound type and location Associated contamination Treatment provided Infection Management Antibiotics & keep wound clean Gangrene Deep space infection of anerobic bacteria Bacterial Gas and Odor Tetanus Lockjaw
Other Wound Complications Impaired Hemostasis Medications Anticoagulants Aspirin Warfarin (Coumadin) Heparin Antifibrinolytics Re-Bleeding Delayed Healing Compartment Syndrome Abnormal Scar Formation Pressure Injuries Cont Careful initial and repeat assessment of the patient and the wound will help the clinician in selecting treatment modalities and evaluating progress. The examination includes notation of the location, depth, and dimensions of the wound, evaluation of the wound bed and the surrounding skin, and analysis of any odor or exudate that may be present. Important wound characteristics to be documented are:
1. Location Anatomic location of the wound is important. The time required for complete healing is affected by the blood supply to the region. For this reason, wounds on the face generally heal faster than a similar wound in a peripheral area where the blood supply is poorer. The rate of healing is also affected by the extent to which the skin is tightly adherent to the underlying fascia. For example, wounds on the shin generally heal slower than comparable wounds anywhere else because skin adherence is so tight over the shin (Baranoski,S., Ayello, E.A., 2004).
Wound Assessment and Documentation
WOUND ASSESSMENT
SIZE AND DEPTH Measure or trace wound area. Measure depth
WOUND EDGES Assess for undermining and condition of margins
SURROUNDING SKIN Assess for color, moisture, suppleness
WOUND BED Assess for necrotic and granulation tissue, fibrin slough, exudate
2. Wound Dimensions Size: the initial size of a wound is an important factor in noting the rate of healing. Large deep wounds take longer to heal than small deep wounds. By contrast, large shallow wounds, like skin-graft donor sites, are covered with new epithelium at about the same rate as small shallow wounds, especially when kept moist. Measure and document the wound upon admission and every Monday using centimeters as follows: 1. Length - longest point on wound, from head to toe. 2. Width - widest point on wound, from side to side. 3. Depth- the deepest point in the wound
Length x width x depth
3. Depth The depth of a wound profoundly affects time to healing. Wounds left to heal by formation of granulation tissue are classified by depth. To measure the depth of deep wounds, gently insert a gloved finger into the deepest part of the wound bed. Mark and measure against a centimeter ruler (Kerstein, 1997). Document findings in the medical record.
4. Undermining Tissue destruction that occurs around the wound perimeter under intact skin where edges have pulled away from wound base. Document the location and amount. (Baranoski & Ayello, 2004)
5. Wound Bed The condition and appearance of the wound bed provides information about the progress of healing and the effectiveness of treatment. The presence of granulation tissue indicates that healing is progressing. A significant amount of fibrin slough or necrotic tissue in the wound bed suggests inadequate wound debridement. Document appearance of the wound bed.
6. Necrotic Tissue Dead devitalized avascular tissue and may impede wound healing. It may be present in the wound as yellow, gray, brown or black. Yellow or tan stringy tissue is referred to as slough. Black devitalized tissue is eschar. Document color, type and percentage of tissue in the wound bed. (Baranoski & Ayello, 2004)
7. Exudate Visual appraisal of the amount and character of wound drainage is generally regarded as an important parameter in wound assessment. One study showed the healing rate of wounds was slowed by two-thirds when exudate was present at baseline. The amount of exudate may be an important indicator of healing. (Xakellis & Chrischilles, 1992). Document exudate color, consistency, odor and amount.
8. Surrounding Skin Monitor and document wound margins for signs of inflammation (erythema, swelling, pain) or maceration (waterlogged). Inflammation may be caused by unrelieved pressure, infection or adverse reactions to wound care treatments. Skin maceration, caused by prolonged contact of wound fluid with the skin, may be a sign that the topical wound treatment is inappropriate for the patient. Document periwound condition.
9. Induration Induration is an area of hardened tissue that can be palpated around a pressure ulcer or wound. Use fingertips to palpate for induration on intact skin surrounding a pressure ulcer or wound. Document induration and extent of wound margin.
10. Infection Occurs in viable tissue beneath the wound surface. Clinical signs of wound infection are the presence of warmth, pain, erythema, swelling, induration, and/or purulent drainage. Infection occurs when the bacterial burden overwhelms the host. Assess the peri-wound tissue for cellulitis. A tissue biopsy should be obtained to confirm infection. Document signs of infection and contact APN / CWOCN and/or physician.
Sterile & Non-sterile Dressings Sterile: Direct wound contact Non-sterile: Bulk dressing above sterile Adherent/Non-adherent Dressings Adherent: stick to blood or fluid Absorbent/Non-absorbent Absorbent: soak up blood or fluids Wet/Dry Dressings Wet: Burns, postoperative wounds (Sterile NS) Dry: Most common Dressing & Bandage Materials Gauze bandage Single ply, non-stretch: 1-3 Adhesive bandages Elastic (Ace) Bandages Triangular Bandages Dressing & Bandage Materials TERIMA KASIH